Obliterated Cul-De-Sac in Endometriosis: Retrograde Dissection of Rectum

Study Objective To demonstrate a retrograde dissection technique for safe management of the obliterated cul-de-sac during hysterectomy in stage IV endometriosis. Design A case report. Setting Academic tertiary care hospital. Patients or Participants 50-year-old G3P3 with chronic pelvic pain and abnormal uterine bleeding requiring blood transfusion who failed medical management and was referred to our clinic for definitive surgical management. Her surgical history is significant for three prior cesarean sections and tubal ligation. Pelvic ultrasound notable for fundal fibroid, left ovary with 8 cm cystic mass and left hematosalpinx. Interventions Patient placed in dorsal lithotomy in Trendelenburg position with uterine manipulator in place. Patient underwent robotic-assisted laparoscopic hysterectomy, bilateral salpingectomy and left oophorectomy with lysis of adhesions and bilateral ureterolysis. Measurements and Main Results The obliterated cul-de-sac can pose risk for injury to rectum, ureters and hypogastric nerves during hysterectomy. Here, we present a technique to safely dissect rectum from the obliterated cul-de-sac. First, we show bilateral ureterolysis and ligation of uterine artery at the origin to decrease risk of ureteral injury and for early control of blood supply. We show mobilization of the sigmoid colon starting above the pelvic brim. We then show a technique to perform dissection of the rectum starting at the rectovaginal septum medial to the uterosacral ligaments. The dissection is carried from deep to superficial until the rectosigmoid was completely mobilized. The remainder of hysterectomy and resection of side wall endometriosis was thus completed without any complications. Final pathology was consistent with 18cm endometrioma and uterine leiomyoma. Conclusion The retrograde technique to dissect the obliterated cul de sac in stage IV endometriosis is a safe surgical approach to restore normal anatomy in advanced endometriosis. These steps will help surgeon access correct surgical planes to minimize risk of injury and blood loss.